Cross-cutting issues: disability

Cross-cutting issues are defined as those which have an impact on every aspect of our work and therefore require further attention. In the next three steps we select three such issues that are relevant to health in a humanitarian context: disability, being elderly, and women and girls.

In this article, Dr Hannah Kuper looks at why disability is an often neglected topic in humanitarian settings, even though conflict and natural disasters can generate more disabled people through injury. This sector of the population is particularly vulnerable before, during, and after a humanitarian crisis occurs as they are often unable to protect themselves or properly seek care once a crisis has passed.

Setting the scene: disability and humanitarian crises

Imagine a woman living in Nepal who has great difficulty walking. Perhaps she is an older woman who has had a stroke or suffers from arthritis. Statistically, she is more likely to be poor than other people living in her village, and so her house may be less sturdy. Now an earthquake strikes. What chance will she have of not being hurt while sheltering in her sub-standard accommodation? If a conflict occurs, will she be able to escape? If a disease outbreak strikes, will she be able to access the vaccines or treatment needed to stay well?

This imagined story reflects the high vulnerability experienced by many people with disabilities in humanitarian crisis settings, whether these are due to natural disasters, conflicts, or disease outbreaks. This is not an unusual scenario as there are an estimated one billion people with disabilities globally, or one in seven people overall, making disabled people potentially the world’s biggest minority group1.

What is disability?

Definitions of disability vary, but broadly speaking people with disabilities are those who are not able to participate fully in society due to a combination of an underlying health condition or impairment and unfavourable social or environmental factors. An example could be a child who is blind and not able to go to school, because s/he does not have a guide dog or stick to help them move around (an environmental factor) or because the teacher is not trained in how to teach them (a social factor).

Why are people with disabilities vulnerable in humanitarian crises?

There are many factors that make people with disabilities more vulnerable in a humanitarian crisis. All people with disabilities will have an underlying impairment, whether this is a physical impairment, problems with vision, or cognitive difficulties. These factors may make it more difficult for people with disabilities to cope in crisis settings. For instance, they may be less able to escape from conflicts or natural disasters due to inaccessible evacuation routes or because they have lost their assistive devices, such as a wheelchair. In outbreak situations they may find it more difficult to access health services if they lack support from a care-giver or cannot access the information that they need, for example if they are deaf.

Added to this, people with disabilities are on average poorer than those without. This means that they may live in more vulnerable areas or less sturdy housing, making them less resilient when natural disasters strike. Crisis settings may also exacerbate existing conditions if people cannot replace assistive devices or get the medicine that they need. All these factors mean that people with disabilities may suffer more ill health, whether physical, psychological, or emotional as a result of a humanitarian crisis.

At the same time, the crisis may lead to disability, which will have implications for planning the crisis response. In Haiti, for instance, an estimated 1,200-1,500 people had amputations as a result of the 2010 earthquake2, and providing orthopaedic rehabilitation was important in that context. However, the rehabilitation response was poorly organised and fragmented3. As another example, it is becoming clear that Ebola survivors are developing long-term disabilities including depression and difficulties with mobility and vision4, and so rehabilitation will be needed there too, but this does not appear to be a priority in crisis response.

Once relief arrives, it may be more difficult for people with disabilities to access assistance programmes, including health care if they are physically inaccessible or discriminate against people with disabilities, whether intentionally or unintentionally. In some famine relief settings, for example, feeding programmes operate through schools, yet many children with disabilities do not attend school and so cannot benefit from the programme5.

What is the solution?

It is important to ensure that people with disabilities are protected during humanitarian emergencies and provided with access to health care, both for ethical reasons and because it is enshrined in international law6. The first step towards this goal is to plan for inclusion of people with disabilities before the disaster, not in its midst. There are guidelines to help with this process7 but it is not clear if these recommendations are often put into practice.

Any humanitarian response should adopt a ‘twin-track’ approach, meaning that plans should be put in place both to ensure that people with disabilities are included in all efforts, e.g. making sure that staff do not discriminate and that buildings and materials are accessible, as well as to address the particular needs of people with disabilities, such as through provision of assistive devices or sign language interpreters. In the Sahel food crisis, a twin-track programme was established in Niger8. Efforts were made to ensure that people with disabilities could access the mainstream cash transfers to buy food, and in addition support groups of people with disabilities were established to further promote their productivity, and help them link to necessary services.

Collecting data is another important priority as ‘what isn’t counted does not count’ and so more evidence is needed to highlight the vulnerability of disabled people in humanitarian crises, as well as to identify how response efforts can be made more inclusive. Currently, lack of data is probably the biggest challenge in advocating and planning for the inclusion of people with disabilities in humanitarian responses.

These efforts will be most effective if people with disabilities are included in planning and implementation, as they are the experts of their own situation8.